Nursing 126 Ch. 17 - Schizophrenia

Antipsychotics side effects produce

EPS,TD, anticholinergic effects, sedation, and orthostatic hypotension. Thorazine is Haldol

Assess in the family

Hx of mental illness Communication patterns Coping mechanisms Family stress and cohesion Spiritual and religious systems

Explain the mechanism of action in Extrapyramidal Symptoms (EPS)

come from blocking action of dopamine in parts of the brain related to movement. - by blocking dopamine, imbalance made between ACh and Da, creating movement probs - anticholinergic drug restores imbalance

Positive symptoms-

hallucinations delusions bizarre behavior speech pattern alterations

Personal boundary difficulties

-clients often lack a sense of where their bodies end in a relationship to where others begin. They also might say they are merging with inanimate objects.

depersonalization

to make impersonal; deprive of personality or individuality

A client with paranoid schizophrenia refuses food. He states the voices are telling him the food is contaminated and will change him from a male to a female. A therapeutic response for the nurse would be A. "You are safe here in the hospital, nothing bad will happen to you." B. "The voices are wrong about the hospital food. It is not contaminated." C. "I understand that the voices are very real to you, but I do not hear them." D. "Other people are eating the food and nothing is happening to them."

"I understand that the voices are very real to you, but I do not hear them."

You are attempting to interview Mr. Jones, a newly admitted involuntary patient with schizophrenia. Mr. Jones seems evasive and uncomfortable and gives one-word responses that are minimally informative. Which response would be most useful for facilitating the interview? 1. "Why did you come to the hospital today?" 2. "It must be difficult to be admitted to a hospital against your will." 3. "If you could cooperate for just a few minutes, we could get this done." 4. "Did your schizophrenia get worse because you stopped taking your medication?"

"It must be difficult to be admitted to a hospital against your will."

When a client with paranoid schizophrenia tells the nurse "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be A. "You are safe here. This is a locked unit and no one can get in." B. "I do not believe I understand the word volmers. Tell me more about them." C. "Why do you think someone or something is going to harm you?" D. "It must be frightening to think something is going to harm you."

"It must be frightening to think something is going to harm you."

Derealization

-is a false perception that the environment has changed. Both of the above can be interpreted as loss of ego boundaries.

Depersonalization

-is a non specific feeling that a person has lost his or her identity, that the self is different or unreal.

What are the 5 main Extrapyramidal Side Effects?

1 - Pseudoparkinsonisms 2 - Akathesia 3 - Acute Dystonic Rxn 4 - Tardive Dyskinesia 5 - Neuroleptic Malignant Syndrome (NMS)

Which of the following would be assessed as a negative symptom of schizophrenia? A. Anhedonia B. Hostility C. Agitation D. Hallucinations

Anhedonia

Other drugs used together with antipsychotics

Antidepressants Antimanic Benzodiazepines ECT

How to assess whether a person is hallucinating

Ask client what they are hearing, seeing and observe behavior that might indicate one is attending to internal stimuli Ask the client to describe the experience and note differences from your perception Ask what the voices are saying

Assessment guidelines

Assess whether the client has a medical condition or substance induced psychosis Assess whether the client is an alcoholic Assess for command hallucinations Assess the client's belief system Assess co-occurring disorders Assess for medications Assess family's response Assess the way family and client relate Assess support system Assess GAF

Jim is sometimes seen moving his lips silently or murmuring to himself when he does not realize others are watching. Sometimes when he is conversing with others, he suddenly stops, appears distracted for a moment, and then resumes. Based on these observations, Jim most likely is experiencing which symptom(s)? Select all that apply. 1. Illusions 2. Paranoia 3. Delusional thinking 4. Auditory hallucinations 5. Impaired reality testing 6. Stereotyped behaviors

Auditory hallucinations Impaired reality testing

A client has been receiving antipsychotic medication for 6 weeks. At her clinic appointment she tells the nurse that her hallucinations are nearly gone and that she can concentrate fairly well. She states her only problem is "the flu" that she's had for 2 days. She mentions having a fever and a very sore throat. The nurse should A. suggest that the client take something for her fever and get extra rest. B. advise the physician that the client should be admitted to the hospital. C. arrange for the client to have blood drawn for a white blood cell count. D. consider recommending a change of antipsychotic medication.

arrange for the client to have blood drawn for a white blood cell count.

Schizophrenia

It is a devastating brain disease characterized by profound withdrawal from interpersonal relationships; cognitive and perceptual disturbances. Loss of contact with reality. It is also described as a psychotic disorder.

A desired outcome for a client with schizophrenia who has a nursing diagnosis of Disturbed sensory perception: auditory hallucinations related to neurobiological dysfunction would be that the client will A. ask for validation of reality. B. describe content of hallucinations. C. demonstrate a cool, aloof demeanor. D. identify prodromal symptoms of disorder.

ask for validation of reality.

Alterations in speech:

associative looseness neologisms echolalia clang association word salad

The type of altered perception most commonly experienced by clients with schizophrenia is A. delusions. B. illusions. C. tactile hallucinations. D. auditory hallucinations.

auditory hallucinations.

Toxic effects of antipsychotics

Neuroleptic malignant syndrome NMS Agranulocytosis Liver involvement

Dystonia

Prolonged invol. muscular contractions that may cause twisting (torsion) of body parts, repetitive movements, and increased muscular tone. Legs usually affected first in children. Progression rare in adults.

Antipsychotics

The standard antipsychotics are used to treat the positive

The abnormal involuntary movement scale AIMS

This is done approx every few weeks with clients on antipsychotic therapy. ` The following is tested: Facial and oral movements Extremity movements Trunk movement Global judgments Dental status

Schizophrenia is best characterized as A. split personality. B. multiple personalities. C. ambivalent personality. D. deteriorating personality.

deteriorating personality.

A descriptor for a subtype of schizophrenia is A. delusional. B. dissociated. C. disorganized. D. developmental.

disorganized.

Tangential

disturbance in associative thought process in which pattern of speech characterized by oblique, digressive, or irrelevant replies to questions; the responses never approach the point of the questions. different from circumstantiality in that circ. eventually reaches the point.

circumstantiality

disturbance of associative thought & speech processes in which the pt. digresses into unnecessary details and inappropriate thoughts before communicating central idea. (schizo, obsessions, dementia)

A withdrawn client is assessed as having distorted thinking that is not reality based. A nursing diagnosis that should be considered for her would be A. impaired verbal communication. B. disturbed thought processes. C. disturbed self-esteem. D. defensive coping.

disturbed thought processes.

A client with disorganized schizophrenia would have greatest difficulty with the nurse A. interacting with a neutral attitude. B. using concrete language. C. giving multistep directions. D. providing nutritional supplements

giving multistep directions.

Thought disorder

is a frequent inability to sort, interpret, and respond to stimuli in a logical way. It is very hard for them to communicate and relate to others.

When a client with schizophrenia hears hallucinated voices saying he is a vile human being, the nurse can correctly assume that the hallucination A. is a projection of the client's own feelings. B. derives from neuronal impulse misfiring. C. is a retained memory fragment. D. may signal seizure onset.

is a projection of the client's own feelings.

A client with residual schizophrenia is uninterested in community activities. He lacks initiative, demonstrates both poverty of content of speech and poverty of speech, and seems unable to follow the schedule for taking his antipsychotic medication. The case manager continues to direct his care with the knowledge that his behavior is most likely prompted by A. chronic uncooperativeness. B. personality conflict. C. neural dysfunction. D. dependency needs.

neural dysfunction.

concrete thinking

overemphasis on specific details and impairment in ability to use abstract concepts. ex. nurse asks pt meaning of "people in glass house shouldn't throw stones" pt. answers, "don't throw or windows will break." answer is literal, abstract thinking absent.

grandiosity

person's unrealistic and exaggerated concept of self-worth, importance, wealth, and ability

What is the most common course of schizophrenia? Initial episode followed by A. recurrent acute exacerbations and deterioration. B. recurrent acute exacerbations. C. continuous deterioration. D. complete recovery.

recurrent acute exacerbations and deterioration.

Psychotic disorder

refers to delusions, any prominent hallucinations, disorganized speech, or disorganized catatonic behavior

A client has reached the stable plateau phase of schizophrenia. An appropriate clinical focus for planning would be A. safety and crisis intervention. B. acute symptom stabilization. C. stress and vulnerability assessment. D. social, vocational, and self-care skills.

social, vocational, and self-care skills

The purpose for a nurse periodically performing the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has schizophrenia is early detection of A. acute dystonia. B. tardive dyskinesia. C. cholestatic jaundice. D. pseudoparkinsonism.

tardive dyskinesia.

A nursing intervention designed to help a schizophrenic client manage relapse is to A. schedule the client to attend group therapy. B. teach the client and family about behaviors associated with relapse. C. remind the client of the need to return for periodic blood draws. D. help the client and family adapt to the stigma of chronic mental illness.

teach the client and family about behaviors associated with relapse.

The causation of schizophrenia is currently understood to be A. a combination of inherited and nongenetic factors. B. excessive amounts of the neurotransmitter dopamine. C. excessive amounts of the neurotransmitter serotonin. D. stress related.

a combination of inherited and nongenetic factors.

A client with paranoid schizophrenia tells the nurse "I have to get away. The volmers are coming to execute me." The term "volmers" can be assessed as A. a neologism. B. clang association. C. blocking. D. a delusion.

a neologism

The atypical antipsychotics

are used to treat the positive and negative s/s of schizophrenia. They have few or no EPS or TDs. They may improve the neurocognitive defects associated with schizophrenia.

Nursing interventions for clients with schizophrenia

A. Withdrawal B. Mutism C. Immobility D. Excessive activity E. Suspicion of others F.Communication deficits G. Inappropriate behavior H. delusions and hallucinations

The age of onset

Adolescence or early adulthood. People who already have sensory deficits may develop schizophrenia as they age. The aging process causes increased isolation and loss of other sensory stimuli

Bleuler's "Four A's" of schizophrenia

Affect-flat, blunt, inappropriate bizarre Association looseness-haphazard and confused thinking Autism-thinking not bound to reality Ambivalence-have two opposing emotions, attitudes, ideas, or wishes toward the same person, situation, or object at the same time

Which symptom would not be assessed as a positive symptom of schizophrenia? A. Delusion of persecution B. Auditory hallucinations C. Affective flattening D. Idea of reference

Affective flattening

Negative signs and symptoms of schizophrenia

Affective flattening Alogia Avolition Apathy Anhedonia Attention deficits Inappropriate affect and bizarre affect These are the most devastating affects on clients ability to function.

A week later, Mr. Jones has begun to take the conventional antipsychotic haloperidol. You approach him with his bedtime dose and notice that he is sitting very stiffly and immobile. When you approach, you notice that he is diaphoretic, and when you ask if he is okay he seems unable to turn towards you or to respond verbally. You also notice that his eyes are aimed sharply upward and he seems frightened. How should the nurse respond? Select all that apply. 1. Begin to wipe him with a washcloth wet with cold water or alcohol. 2. Hold his medication, stat page his doctor, and check his temperature. 3. Administer a medication such as benztropine IM to correct his dystonic reaction. 4. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass. 5. Explain that he has anticholinergic toxicity, hold his meds, and give IM physostigmine. 6. Hold his medication tonight, and consult his doctor after completing medication rounds.

Begin to wipe him with a washcloth wet with cold water or alcohol. Hold his medication, stat page his doctor, and check his temperature.

Alterations in behavior:

Bizarre behavior-eccentric dress or grooming, rituals, stilted rigid demeanor Extreme motor agitation Stereotyped behaviors Automatic obedience Waxy flexibility Stupor Negativism

A patient is found in a closet with an empty 2-liter bottle of cola taken from the staff refrigerator. The bottle was full but now is empty. Recently, staff have noticed an increase in this patient's response to auditory hallucinations and the recent addition of confusion to his symptoms. For the past several days, the patient has been seen drinking from the hallway water cooler and taking items from his peers' dinner trays. Which response is most appropriate? 1. Place the patient on every-15-minute checks to identify any further deterioration. 2. Restrict his access to fluids, and evaluate for water intoxication via daily weights. 3. Attempt to distract the patient from excess fluid intake and other bizarre behavior. 4. Request an increase in antipsychotic medication, owing to the worsening of his psychosis.

Restrict his access to fluids, and evaluate for water intoxication via daily weights.

Other psychotic disorders

Schizophreniform Brief psychotic disorder Schizoaffective disorder Delusional disorder Shared psychotic disorder( Folie a Deux) Induced or secondary psychosis Psychosis induced polydipsia

Mary, a patient diagnosed with schizophrenia, is encouraged to attend groups but stays in her room instead. Staff and peers encourage her participation, but her hygiene remains poor. She does not seem to care that others wish that she would behave differently. Which is the most likely explanation for Mary's failure to respond to others' efforts to help her behave in a more adaptive fashion? Select all that apply. 1. She is avolitional. 2. She is displaying anergia. 3. She is displaying negativism. 4. She is exhibiting paranoid delusions. 5. She is being resistant or oppositional. 6. She is experiencing social withdrawal. 7. She is apathetic due to her schizophrenia.

She is avolitional. She is displaying anergia. She is displaying negativism. She is experiencing social withdrawal. She is apathetic due to her schizophrenia.

2 groups of antipsychotics

Standard- traditional dopamine antagonists Atypical- serotonin-dopamine antagonists Treatment of choice is individualized based on the adverse side effects

Blocking

Sudden break in free association as a defense mechanism against unpleasant ideas.

Which side effect of antipsychotic medication has no known treatment? A. Anticholinergic effects B. Pseudoparkinsonism C. Dystonic reaction D. Tardive dyskinesia

Tardive dyskinesia